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DVANCING SOCIAL WORK PRACTICE IN THE HEALTH FIELD: A COLLABORATIVE RESEARCH PARTNERSHIP MARION BOGO, LILIAN WELLS, SHARON ABBEY, ANN BERGMAN, VERNA CHANDLER, LEOTA EMBLETON, SAMIRA GUIRGIS, ANNE HUOT, TED MCNEILL, LINDA PRENTICE, DAN STAPLETON, LORIE SHEKTER-WOLFSON, and SORELE URMAN This article describes and analyzes the development of a collaborative research model by one university faculty of social work and 10 health care settings. Established working relationships for educating students were the foundation of a research partnership formed to study questions of mutual interest. This article discusses the developmental stage of the research consortium, including needs assessment, workshop, identification of a common theme and research topic, preliminary funding, and literature review. This stage resulted in the decision to develop and test an instrument to screen for high social risk that would be capable of identifying the need for social work involvement with families to provide effective and efficient management of patients. The Delphi methodology was chosen in the first phase of the research design, and reasons for the choice of this methodology, the results from the two Delphi rounds, and a preliminary screening instrument are presented. Finally, issues in collaboration, such as institutional factors, dynamics of the working group, and leadership roles, are analyzed to identify facilitating features and problematic issues in such partnerships.
The development of practice knowledge through empirical studies is the traditionally accepted mandate of a professional school in a university. Service-delivery organizations are com-
mitted to using the most current knowledge in their practice. When such organizations are affiliated with a university, a structure may be created for collaboration in research that is most
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relevant to practice and in practice that is enhanced by research. High-quality professional education and practice require such collaboration to identify current concerns and to ensure that research is directed to the solution of practice-relevant problems. A number of writers in the health field have argued for collaboration between health care professionals and academic settings (Irvine, Phillips, Fisher, & Cloonan, 1989; Reinherz, Grob, & Berkman, 1983). Such efforts can merge the diverse knowledge and talents of various personnel (Haunch, Chance, & Atwood, 1981) and involve a wide representation of professionals such as clinicians, administrators, researchers, and educators (Baker, 1981; Engstram, 1984; Musci, 1987). Collaboration offers a broader base for the generation of ideas (Musci, 1987), the design and implementation of research (Engstram, 1984), and the solution of problems during implementation. Young (1986) pointed out that social workers possess the necessary skins for effective collaboration, including the ability to work with people and to deal with organizational structuren. Social work educators have stressed the need for collaborative activities between academic and practice settings. Caroff and Mailick (1985) and Marshack, Davidson, and Mizrahi (1988) described methods to develop relevant educational curricula. Reinherz et al. (1983) described one such partnership, in which research teaching took place in faculty-led research projects in health care agencies. Despite the recognition of the importance of collaboration in knowledge building, there is a surprising lack of social work literature describing the various approaches that academicians and practitioners might use. This article presents a new university—agency partnership model designed to lead to increased practice effectiveness. CONTEXT At the University of Toronto, formal links were strengthened between the social work faculty and health care organizations when a health specialization curriculum was developed in 1979. The specialization consisted of a cohort of fac224
ulty, students, and practicum settings. Formal courses were offered in health-related topics such as social work practice in health, health policy, health and illness issues, and research in health settings. These courses were consistent with the criteria identified by Caroff and Mailick (1985) in their survey of social work schools that offer health specializations. Field workers who identified themselves as part of the health specialization devoted considerable resources to working with faculty to design the health curriculum. Elements of the design included identifying appropriate learning objectives for students at various levels of education, integrating learning opportunities for direct and organizational practice, and articulating the role of an agency-based educational coordinator to develop and administer the program. A number of health care settings entered into a long-term partnership with the social work faculty, established a formal contract, and were designated as teaching centers. Teaching centers mandated social work education as one of their objectives and committed health care organizations to the development of social work practice knowledge. At the University of Toronto, the social work administrator and a senior staff member were appointed as adjunct social work practice professors. The senior staff member became the educational coordinator and was responsible for developing and offering an educational program to a cohort of students. Such a program involved more than the traditional apprenticeship model of education, which relies solely on the student being assigned to one instructor. Instead, students had the opportunity to learn from more than one instructor and to have clients from various services. Educational seminars especially for students were developed to present specific areas of practice-related knowledge. The seminars also provided opportunities for integration of particular experiences within the broader context of the health care organization and the health field. The Association of Field Practice Educators, an organization of social work administrators and field instructors, is represented on all policymaking bodies of the faculty of social work.
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Many of the social work administrators and educational coordinators in the health care settings were active members of the association and participated in developing curriculum policy and program change. Through developing teaching centers, offering practicums to a substantial number of students, and participating in the Association of Field Practice Educators, a productive working relationship developed between social work administrators and educational coordinators and faculty members. These activities provided the foundation for developing a model of collaborative research that emanates from the educational partnership but focuses on practice issues rather than student education.
STEPS IN THE DEVELOPMENT OF A COLLABORATIVE RESEARCH PROJECT Needs Assessment
A survey of the research interests, needs, and capabilities in 10 health settings was conducted over a four-month period. Needs assessment was conducted through individual interviews guided by a standardized questionnaire. Although a few social work departments, particularly those in institutions where a major goal was research, were already involved in research projects, the majority of social work departments interviewed were not conducting any studies. Responses were characterized by marked commonality. All participants readily acknowledged the importance of research and linked this concern with organizational pressures for quality assurance and accountability. However, heavy staff workloads, budget cutbacks, and constant demands to defend social work programs and their effectiveness left the social work administrators feeling overburdened and beleaguered. Although they valued research, they rarely had resources for projects. Most administrators believed there was merit in pooling the respective expertise of the faculty and the setting in identifying a question of mutual interest. These 10 settings made an initial commitment to work together to develop an action plan.
Workshop
A workshop was convened to present the results of the needs assessment. Because all participants experienced conflicting feelings about engaging in research, it was necessary to identify negative as well as positive feelings. Many participants felt that the proposed research constituted another expectation or demand from the faculty. Mistrust regarding the faculty's motivation was evident. Was this interest in practice research a veiled way of changing practicum education and demanding more of field instructors? It was important to clarify the faculty's stance in this regard. A closer integration of practicum, practice theory, and research was recognized as ultimately desirable for social work; however, the objective at this stage was to form a consortium to develop a research project responsive to the practice knowledge needs of the settings. As participants worked together they saw that the faculty did not have a hidden agenda. Repeated discussion and clarification of the issue was helpful in developing trust. It was also important that everyone was able to express concerns directly so these concerns could be addressed. This type of project needs participants and facilitators who will ensure that contentious issues are aired and dealt with. Although communication was important to initiate the collaborative research relationship, the ongoing behavior of the members appeared most critical in facilitating the partnership and allaying mistrust. The positive feelings emanating from a shared belief that empirically derived practice knowledge is necessary and useful to achieve positive practice outcomes propelled people to join a consortium. They realized that objective data could help social work administrators respond to organizational pressures to demonstrate the effectiveness of their services. In university hospitals, research is accorded high status, and through participation in a consortium those social work departments would be serving their organizations' mandate for research. By the end of the workshop, the cohort of representatives from health settings decided that rather than engage in a number of small
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individual projects, it was desirable instead to develop a research consortium in partnership with the social work faculty. Each setting appointed a representative, often the director of social work. The following four working principles emerged: 1. For participating social work departments, research would become an objective supported by senior administration. 2. A common theme would be identified for study that would be important to all settings. 3. The theme should be of interest to both frontline staff and social work administration. 4. The product of the research should be useful in practice. Identification of a Common Theme and Research Topic
Over a four-month period, a consultative process was undertaken within and among organizations to delineate a research topic. The consortium consisted of acute care general hospitals, a pediatric hospital, a health complex serving elderly people, a hospital specializing in chronic care and rehabilitation, and a center specializing in addiction treatment. All participants recognized that the capacity of the consortium to obtain research funding would be strengthened by the number and diversity of settings. In addition, a university–multiorganization research partnership was likely to be accorded higher status in each organization than a single department research initiative. Hence, it was in everyone's interests to find a theme broad enough to encompass the specific practice issues of the various settings. The researchers suggested that data be analyzed separately for each setting to yield information useful to particular organizations and to permit comparisons between them. The representatives from each setting engaged in discussion with their social work staff to elicit their perceptions of important practice questions needing empirically based answers. Early frontline staff involvement was seen as critical for a number of reasons. Their input would help ensure that research questions would lead to increased practice knowledge 226
and effectiveness. It was important to identify and respond to staff concerns that could become barriers to research so that cooperation in the implementation phase would be more likely. Early staff involvement was seen as important to enhancing the chance of appropriate use of the findings. Topics that emerged from the discussions in the 10 health care settings included a methodology to determine the rational allocation of social work resources according to professional knowledge, skill, values, and organizational needs; the development and use of instruments to screen for high social risk; the role of social services in the care of the aged population; social work methods for serving an increasing ethnic population; the development of valid and reliable methods to facilitate productivity; and the development of social work methods to enhance family involvement in the care and management of patients. The following criteria were applied to all the topics in an attempt to develop a priority list: potential for funding, perception of the topic as important by frontline staff, low staff time requirement, ready availability of the data to be collected, and collection of data from staff rather than from patients to simplify ethical review across settings. These criteria were applied to all the topics generated from discussions with more than 100 social workers in the 10 settings. The topic they developed—to develop and test an instrument to screen for high risk that would be capable of identifying the need for family involvement in the effectave and efficient management of patients—was chosen because it met the criteria and represented an issue of sufficiently broad appeal to all members of the consortium. This topic seemed particularly pertinent because an increasing awareness has emerged regarding the role of the family in the medical treatment of illness and disability. Social work traditionally has addressed the psychosocial impact of illness on family stability and the health of family members. Therefore, it is important to identity indicators and predictors for referral of family members for social work services. The researchers decided to develop a screening instrument to facilitate social work services to the
HEALTH AND SOCIAL WORK/ VOLUME 17, NUMBER 3 /AUGUST 1992
most needy families. It was expected that such an instrument would assist in the later identification of social work technologies that facilitate quality care for families and would create practice standards of social work for families in health care settings. Preliminary Funding
Any research development activity needs a thorough literature review, instrument development and administration, preliminary data analysis, and the writing of complex funding proposals. These activities require funding. This need must be acknowledged at the outset, and the university should provide start-up funds or research assistance. Fund-raising plans for all participants should allo be developed immediately. Faculty presented a preliminary funding proposal to the university for start-up funds and developed a flow chart of the steps in the research process (Figure 1). The university provided a small research grant. Many consortium members sought funding from their respective institutions. Interhospital rivalry was used productively by the participants to convince their hospital administrators to participate, as was the uniqueness of the large number of participating organizations in partnership with the university. The 10 participating health care settings contributed the requested amount of $500. Literature Review
Suggestions for appropriate literature for review were secured from all staff. The researchera employed a social worker from one of the health care settings to conduct a preliminary analysis of the literature. When funds were secured, a research associate was hired to complete a systematic literature search and review (Bergman, Aggey, Bogo, & Wells, 1990). The literature indicated a lack of previous work in the area and was not specific in defining high-risk indicators for family referral, although there were many reports of the importance of work with families. High-risk screening instruments for general social work referral tend to
identify patients without families as being in special need of social work services. IMPLEMENTATION
Because of the lack of current research and the accepted belief that severity of need or high risk is a judgmental phenomenon and should be defined by the opinion of expert clinicians and theoreticians (Gustafson et al., 1986), the authors tapped the opinions of social work practitioners. The Delphi method was chosen and used in two rounds over a six-month period. The Delphi method is a means of obtaining expert opinion in a systematic manner. Developed in 1984, it is one of a group of methods used in health care and other fields to obtain consensus. The Delphi method is a communication process that facilitates the merging of diverse opinions from a dispersed population into a collective decision. Participants complete a mailed questionnaire. The results are tabulated and reported to the group. These results lead to more specific questions in the second "round," and again results are tabulated and reported. This iterative process continues until sufficient information exchange has been obtained (Delbecq, Van de Ven, & Gustafson, 1975). The advantages of the Delphi method are that each participant can express ideas independently while ultimately providing information generated by an entire group (Fink, Kosecoff, Chassin, & Brook, 1984). The process is relatively easy to understand and implement, and it is flexible in that the number of rounds can be adjusted to meet research needs. lis reliability increases with the size of the group and the number of rounds (Fink et al., 1984; Starkweather, Gelwicks, & Newcorner, 1975). Most commonly, three rounds have proved sufficient to attain stability in the responses; further rounds tended to show little change, and excessive repetition was not acceptable to participants (Linstone & Turoff, 1975; Thomson & Ponder, 1979). Consortium faculty members developed a draft questionnaire. The group reviewed the questionnaire to ensure that questions were clear and could be answered by social workers in their settings. This review served as a pretest.
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Figure 1. Steps in the Development of High-Risk Scale for Social Work Referral of Patients' Families
Literature Analysis Phase 1
Review related instruments
Analyze research and theoretical literature
Expert Input
Instrument Development
Validity Analysis
Reliability
Use modified Delphi to tap expertise of social work practitioners
Compile expert judgments
Assemble pool of 200-300 ► items
Review (by practitioners) to ensure comprehensiveness and content validity
Conceptualize~Review (by dimensions to panel of judges) be measured to establish construct validity Phase 2
Select references to literature
Develop list Review by one ► of indicators--► social work practitioner Revise list
Phase 3
Option 1: Use multiattribute decision analysis to develop and revise instruments Option 2: Test on Perform closed factor cases and item analysis analysis
Revise instrument
Phase 4
t
Field test
Use Cronbach's alpha to compute reliability of factors as well as dimensions conceptualized by researchers
Social workers in each of the social work departments in the health care facilities that formed the consortium completed the questionnaire. The first Delphi round asked them to iden in relation to their service, high-risk situations in which the patient's family should be referred for social work services. They were also asked to identify contraindications for such referrals. This round generated 263 indicators for family referral. These indicators were then grouped into 15 categories. At this stage the goal was to be inclusive, and there was some repetition of items across categories. The second Delphi round asked participants to rate each indicator on a four-point scale, ranging from 1 = not important to 4 = very important. They were also asked to identify the four most important indicators in each category. Space was provided to allow participants to add additional items or make other comments. Consortium members, because they meet frequently, were well connected to the research. The frontfine social workers' interest in the project varied between settings and affected their interest in completing the questionnaires. Connection of staff to the research was established through a representative, usually the social work administrator, in each setting. This person oriented staff to the research and sought their participation in the Delphi rounds. More direct connections between the social workers and the entire consortium would likely have led to a greater sense of involvement. A research day between the two Delphi rounds might have achieved this goal. In most instances representatives obtained a high return rate from the social workers. In some settings internal department difficulties, such as workload assignments, authority issues, and interpersonal conflicts, were displaced onto the research. Social workers who had negative experiences with the faculty as former students or as field instructors also used the research as a target for unresolved feelings of dissatisfaction. It was important for the setting representatives to share these negative reactions from the staff with the consortium. Representatives shared these reactions because consortium members trusted each other to maintain confidentiality
and to support the representative who had been the recipient of criticism about the research. Consortium members also needed to differentiate whether criticisms provided objective and useful feedback about the project or were subjective responses to other issues. There were 196 respondents from the 10 health care facilities. Eighty-two percent had a master of social work degree, 10 percent had a bachelor of social work degree, and 8 percent had social services diplomas or other qualifications. The range of services covered reflected the span of hospital departments. Medicine was the most frequent service reported, followed by psychiatry, geriatrics, rehabilitation and chronic care, and surgery. Surgical areas were frequently carried as a secondary service. More specific services such as intensive care and crisis units, addiction treatment, and acquired immune deficiency syndrome—related care were also identified. Twothirds of the workers reported that more than 75 percent of their assessments included families. There were no major differences across services in indicators of high risk. However, people who worked with children and elderly people identified abuse as an indicator more frequently than those serving the general adult population. After the second Delphi round, the responses were analyzed to identify the items that the respondents rated as indicators of high risk. The consortium members reviewed this list to eliminate duplications. The result was an item pool of 57 listings in 12 categories (Table 1). Thus, the Delphi's first round generated an item pool and the second round provided a rating of the importance of each item as a high-risk indicator for family referral. The results provide a basis for the development of a screening instrument. At this stage a more sophisticated methodology was needed to test and refine the screening instrument. The research consortium developed a major proposal that was submitted to an external funding agency, where it is currently under review. ISSUES IN COLLABORATION
Germain (1984) noted that to achieve effective teamwork, problems related to goals, roles,
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Table 1. Second-Round Delphi Results of the Research Consortium: High-Risk Indicators for Social Work Involvement with Families Indicator
Examples and Comments
Request for social work involvement by patient or family Identification of family problem by patient Problems at initial contact
No apparent organic basis to presenting complaint Presenting symptom related to social stresses, emotional factors, and psychological factors Alcohol abuse or drug use symptoms
Protection concerns
Concern about patient or any family member Physical injury, especially repetitive and unexplained or ambiguously explained injuries Possible neglect, indicated by disheveled, uncared for, or malnourished appearance or lack of visitation by family Possible financial exploitation Sexual abuse or assault Threats to others or self Concerns expressed by patient or family member regarding safety
Basic needs
Employment Finances Home help Help locating, accessing, and using community services Child care Accommodation Transportation Immigration status
Capability of involvement in decision making
Physical or language problems Inability to receive and respond to information in an age-appropriate way Age-inappropriate behavior Confusion in patient
Impact of illness and disability
Illness that affects lifestyle, job, education, activities of daily living, or relationships Catastrophic or life-threatening illness Terminal illness or palliative care Disease that necessitates role changes in family Sudden death of family member Adaptation to chronic illness by patient and family Diagnosis of life-threatening illness (chronic or short-term)
Patient adjustment
Difficulty coping with illness and its diagnosis, prognosis, treatment, or hospitalization Lack of acceptance of limitations and changes resulting from illness Excessive fears, denial, guilt, anxiety, and sadness in patient (continued)
Table 1. Continued Indicator
Examples and Comments
Family characteristics and adjustment
Difficulty managing or coping with patients' behavior Family members' need for help coping with diagnosis, prognosis, treatment, hospitalization, and patient's emotional status or behavior Excessive fear, denial, guilt, anxiety, and sadness in family Need expressed by family for education or guidance regarding coping with member's situation or mental problems Evidence of numerous stress factors, including death, illness, surgery, disability, loss of job, loss of financial resources, relocation issues, and immigration Family avoidance of contact with patient Unplanned or unexpected life transitions, such as crisis occurring at birth, marital or family breakdown, separation of family members
Discharge planning
Need for long-term care or rehabilitation placement Complex, painful, or difficult discharge planning process for patient or family members Need for ongoing support of family on discharge Anticipation of problems on discharge by patient, family, or staff Conflict because of cultural attitudes toward meeting care needs (for example, intergenerational responsibility)
Family caregivers
Issues raised by family in relation to caregiving Evidence that caregiver is struggling or handling patient poorly Inability of family to take on caregiving responsibility (shown by unwillingness, ambivalence, or reluctance) Need by caregiver for guidance, support, and help in decision making Concern about parent's ability to care for child Limited social and family support Suspected alcohol abuse or drug use in caregivers
Family dynamics
Family members fighting, arguing, and disagreeing Family members interfering with planned treatment Patient upset by family behavior Visiting patterns problematic or unusual (for example, family members always or never present) Uncertainty about keeping child Unresolved issues related to reconstituted families
procedures, and organizational issues must be addressed. Goal-related issues needed to be resolved as consortium members struggled to achieve a common purpose. Role-related issues were illustrated by the initial ambivalence of members and when concerns of trust, hidden agendas, and leadership were raised. Procedural issues caused problems when the consortium collected data and at the same time identified whether resistance of some members was related to the task at hand or to preexisting interpersonal issues. The support of the respective organizations in the consortium was seen as a major contributing factor to its establishment and continuation. Both the university and the health care settings identified research activities as an objective. However, actions were needed to demonstrate this commitment. In this instance all the settings provided requested resources such as funding and release time for staff to attend consortium meetings. The involvement of 10 health care settings strengthened the perception that the social work health research consortium was innovative and engaged in a study of significance for social work and health care. The administrations of the settings valued the joint enterprise with the university and in some instances gave it higher status than on-site social work research. During the project's first two years, the majority of the members representing the settings changed employment. The commitment of all settings to the project allowed for continuity, as new representatives were expected to join the consortium and continue the work. Motivation and Trust in the Working Group
Typically, university-based researchers formulate a research topic and use a practice setting to obtain data. As a result consortium members were concerned about the motivation of faculty outreach. Were faculty members operating out of self-interest? Did they have a hidden agenda? Would agency social workers do the work and the faculty take credit? How would agency-based social workers benefit? Would faculty manipulate the decision-making process? These con232
cerns led to challenges about faculty motivation and control. Similarly, faculty had reservations. Would they invest time and energy in developing the project only to find resistance to implementation? Could a group of 12 social workers from a variety of settings and with varying research backgrounds work productively? Would there be equitable involvement in tasks and sharing of credit? These concerns about motivation and self-interest of participants coupled with the problem of changing agency representation could have been major barriers to progress. Consortium members were skilled in collaborative practice; it was part of their function as social workers in health care (Germain, 1984). Typically they used confrontation—that is, open discussion of concerns and differing opinions, analysis of causes, and problem solving—rather than other styles of conflict management such as avoidance or forcing a solution through exertion of power (Rubin & Beckford, 1972). Thus, problems were reframed as opportunities for consolidating the working alliance among consortium members. Leadership Roles
Initially the faculty provided leadership, but increasingly the agency members assumed greater responsibility by supporting each other, ensuring absent members were updated, and working together in subgroups. The start-up funds facilitated an initial literature review. As work progressed, the tasks became clearer and commitment strengthened. Members developed the enthusiasm to convince the senior executives in their organizations of the importance of the project, to enlist their support, and to raise funds from hospital administration. The social work directors' skill in influencing their administration and the faculty members' expertise in writing funding proposals were pooled to produce a brief proposal to secure funds from the health care settings. Agency members supported each other in developing strategies and tactics to gain the commitment of their social work staff and to engage them in data collection via the Delphi method. Success in fund-raising and in obtaining thoughtful staff responses to the
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Delphi heightened the sense of purpose and confidence. In the early phases representatives from the settings changed frequently. New consortium members had to be educated about the project and brought into the group. As each new member joined, their questions about the project stimulated the ongoing group to clarify the work and attend to issues that had been overlooked. This process strengthened the work, as it resulted in frequent review and created group cohesiveness. Data analysis brought a new phase to the process. The faculty analyzed the results of the first Delphi round. After the second round, the faculty demonstrated the tasks involved, the members formed subgroups to work on different sections, and the subgroups brought their results back to the whole group for consensus decisions. Thus, the consortium was involved in the conceptualization of the project and many handson activities such as writing the proposal, evaluating the questionnaire, and defining behavioral indicators in the draft screening instrument. The consortium members worked on these tasks in small and large groups, pooling and sharing expertise. The success of the collaboration appeared to rest on certain characteristics of individual members that resulted in a productive, task-oriented team. Social workers tend to value and be skilled at behaviors that encourage cooperation, positive feedback, development of trust, respect for individual contributions, active problem solving, and direct and open communication. Members risked raising contentious issues regarding power, status, ownership, and hidden motivations. Members remained committed to the task and followed up on assignments. As a result of the success of the collaboration the consortium members decided to apply for a major research grant. This decision demanded a renewed commitment. A junior faculty member was recruited initially to write a literature review and then as a full member of the group to play a primary role in gathering the material required for the proposal. Again the faculty members provided leadership and resources in the
form of staff experienced in research and access to consultation from a range of experts. The consortium opened its membership to include as coinvestigators two academicians, one from social work and the other with a social work background but from the faculty of medicine. Both of these investigators had specialized skills in the research method that had been chosen for the next phase of the research. Again, issues of prestige and control resurfaced. Animosity and resistance were expressed and resolved through a process of reclarification of purpose and role. CONCLUSION
In contrast to research based on outside consultation, the social work health research consortium used a collaborative model that involved all participants in collegial activity. The institutional relationships and accompanying university appointments provided a structural link that was used to involve the social work departments at the initial stage. Because all contributors were seen as equally necessary for the project to be successful, an atmosphere of respect developed in which participants interacted as tolleagues. Group decision making was done by consensus, with influence connected to expertise rather than to a specific role. The outcome of this consortium thus far is the development of conceptualizations of risk factors for social work involvement with families in health settings. The consortium also highlighted the visibility of social work expertise with such families. Research participants gained increased knowledge of research methodology and grantsmanship, and the credibility of social work research in the health care settings was enhanced. Societal pressures for accountability and efficiency support systematic studies, as illustrated by an openness to research on the part of both the institutions and their staffs in this study. In this era of changing demographics, rising health care costs, and shrinking resources, all health care professionals are challenged to find the most effective methods of promoting health and minimizing the negative effects of illness.
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Research activities can help address these concerns and determine effective social work practice interventions. Collaboration between social workers in university and health care settings can provide a fruitful means to advance the empirical base for practice. About the Authors
Marion Bogo, Adv. Dip. SW, is Social Work Practice Professor and Field Practicum Director, Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, Ontario, Canada M5S 1A1. Lilian Wells, Adv. Dip. SW, is Professor and Associate Dean, Faculty of Social Work, University of Toronto. Sharon Abbey, MSW, is Senior Social Worker, Sunnybrook Health Science Centre, Toronto. Ann Bergman, PhD, is Social Work Practice Professor, Faculty of Social Work, University of Toronto. Verna Chandler, MSW, is Director, Social Work Department, Mount. Sinai Hospital, Toronto. Leota Embleton, MSW, was Director, Social Work Department, Queen Elizabeth Hospital, Toronto. Samira Guirgis, MSW, was Senior Social Worker, Addiction Research Foundation, Toronto. Anne Huot, MSW, was Senior Social Worker, Mississauga General Hospital, Mississauga, Ontario. Ted McNeill, MSW, is Director, Social Work Department, Hospital for Sick Children, Toronto. Linda Prentice, MSW, is Senior Social Worker, St. Michael's Hospital, Toronto. Dan Stapleton, MSW, was Director, Social Work Department, Toronto East General Hospital, Toronto. Lorie Shekter-Wolfson, MSW, is Director, Social Work Department, The Toronto Hospital, Toronto. Sorele Urman, MSW, is Director of Central Intake, Baycrest Centre for Geriatric Care, North York, Ontario. References
Baker, C. M. (1981). Moving toward interdependence: Strategies for collaboration. Nurse Educator, 6, 27-31. Bergman, A., Abbey, S., Bogo, M., & Wells, L. (1990). High-risk indicators for family involvement 234
in social work: A review of the literature. Unpublished manuscript, University of Toronto, Faculty of Social Work. Caroff, P., & Mailick, M. D. (1985). Health concentrations in schools of social work: The state of the art. Health and Social Work, 10, 5-14. Delbecq, A. L., Van de Ven, A., & Gustafson, D. H. (1975). Group techniques for program planning. Glenview, IL: Scott, Foresman. Engstram, J. L. (1984). University, agency, and collaborative models for nursing research: An overview. Journal of Nursing Scholarship, 14(3), 76-80. Fink, A., Kosecoff, J., Chassin, M., & Brook, R. H. (1984). Consensus methods: Characteristics and guidelines for use. American Journal of Public Health, 74, 979-983. Germain, C. B. (1984). Social work practice in health care: An ecological perspective. NewYork: Free Press. Gustafson, D. H., Fryback, D. G., Rose, J. H., Yick, V., Prokop, C. T., Detmer, D. E., & Moore, J. (1986). A decision-theoretic methodology for severity index development. Medical Decision Making, 8, 27-35. Haunch, A. S., Chance, H. C., &Atwood, J. (1981). Research in practice: A process of collaboration and negotiation. Journal of Nursing Administration, 11, 33-38. Irvine, A. A., Phillips, E. K, Fisher, M., & Cloonan, P. (1989). Out of the ivory tower: The value of collaborative research. Home Health Care Services Quarterly, 10, 117-130. Linstone, H. A., & Turoff, M. (1975). The Delphi method: Techniques and applications. Reading, MA: Addison-Wesley. Marshack, E., Davidson, K., & Mizrahi, J. (1988). Preparation of social workers for a changing health care environment. Health and Social Work, 13, 226-233. Musci, E. (1987). Collaboration: The key to research feasibility. Oncology Nurse Forum, 14, 84-85. Reinherz, H., Grob, M. C., & Berkman, B. (1983). Health agencies and a school of social work: Practice and research in partnership. Health and Social Work, 8, 40-47. Rubin, I. M., & Beckford, R. (1972). Factors influencing the effectiveness of health teams. Milbank Memorial Fund Quarterly, 50, 317-335.
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Starkweather, D. B., Gelwicks, L., & Newcomer, R. (1975). Delphi forecasting of health care organization. Inquiry, 12, 251-262. Thomson, W. A., & Ponder, L. D. (1979). Use of Delphi methodology to generate a survey instrument to identify priorities for state allied
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health associations. Journal of Allied Health and Behavioral Sciences, 2, 383-399. Young, C. L. (1986). Social work roles in collaborative research. Social Work in Health Care, 11, 71-81. Accepted July 30, 1991
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DVANCING SOCIAL WORK PRACTICE IN THE HEALTH FIELD: A COLLABORATIVE RESEARCH PARTNERSHIP MARION BOGO, LILIAN WELLS, SHARON ABBEY, ANN BERGMAN, VERNA CHANDLER, LEOTA EMBLETON, SAMIRA GUIRGIS, ANNE HUOT, TED MCNEILL, LINDA PRENTICE, DAN STAPLETON, LORIE SHEKTER-WOLFSON, and SORELE URMAN This article describes and analyzes the development of a collaborative research model by one university faculty of social work and 10 health care settings. Established working relationships for educating students were the foundation of a research partnership formed to study questions of mutual interest. This article discusses the developmental stage of the research consortium, including needs assessment, workshop, identification of a common theme and research topic, preliminary funding, and literature review. This stage resulted in the decision to develop and test an instrument to screen for high social risk that would be capable of identifying the need for social work involvement with families to provide effective and efficient management of patients. The Delphi methodology was chosen in the first phase of the research design, and reasons for the choice of this methodology, the results from the two Delphi rounds, and a preliminary screening instrument are presented. Finally, issues in collaboration, such as institutional factors, dynamics of the working group, and leadership roles, are analyzed to identify facilitating features and problematic issues in such partnerships.
The development of practice knowledge through empirical studies is the traditionally accepted mandate of a professional school in a university. Service-delivery organizations are com-
mitted to using the most current knowledge in their practice. When such organizations are affiliated with a university, a structure may be created for collaboration in research that is most
CCC Code: 0360-7283/92 $3.00 © 1992, National Association of Social Workers, Inc.
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relevant to practice and in practice that is enhanced by research. High-quality professional education and practice require such collaboration to identify current concerns and to ensure that research is directed to the solution of practice-relevant problems. A number of writers in the health field have argued for collaboration between health care professionals and academic settings (Irvine, Phillips, Fisher, & Cloonan, 1989; Reinherz, Grob, & Berkman, 1983). Such efforts can merge the diverse knowledge and talents of various personnel (Haunch, Chance, & Atwood, 1981) and involve a wide representation of professionals such as clinicians, administrators, researchers, and educators (Baker, 1981; Engstram, 1984; Musci, 1987). Collaboration offers a broader base for the generation of ideas (Musci, 1987), the design and implementation of research (Engstram, 1984), and the solution of problems during implementation. Young (1986) pointed out that social workers possess the necessary skins for effective collaboration, including the ability to work with people and to deal with organizational structuren. Social work educators have stressed the need for collaborative activities between academic and practice settings. Caroff and Mailick (1985) and Marshack, Davidson, and Mizrahi (1988) described methods to develop relevant educational curricula. Reinherz et al. (1983) described one such partnership, in which research teaching took place in faculty-led research projects in health care agencies. Despite the recognition of the importance of collaboration in knowledge building, there is a surprising lack of social work literature describing the various approaches that academicians and practitioners might use. This article presents a new university—agency partnership model designed to lead to increased practice effectiveness. CONTEXT At the University of Toronto, formal links were strengthened between the social work faculty and health care organizations when a health specialization curriculum was developed in 1979. The specialization consisted of a cohort of fac224
ulty, students, and practicum settings. Formal courses were offered in health-related topics such as social work practice in health, health policy, health and illness issues, and research in health settings. These courses were consistent with the criteria identified by Caroff and Mailick (1985) in their survey of social work schools that offer health specializations. Field workers who identified themselves as part of the health specialization devoted considerable resources to working with faculty to design the health curriculum. Elements of the design included identifying appropriate learning objectives for students at various levels of education, integrating learning opportunities for direct and organizational practice, and articulating the role of an agency-based educational coordinator to develop and administer the program. A number of health care settings entered into a long-term partnership with the social work faculty, established a formal contract, and were designated as teaching centers. Teaching centers mandated social work education as one of their objectives and committed health care organizations to the development of social work practice knowledge. At the University of Toronto, the social work administrator and a senior staff member were appointed as adjunct social work practice professors. The senior staff member became the educational coordinator and was responsible for developing and offering an educational program to a cohort of students. Such a program involved more than the traditional apprenticeship model of education, which relies solely on the student being assigned to one instructor. Instead, students had the opportunity to learn from more than one instructor and to have clients from various services. Educational seminars especially for students were developed to present specific areas of practice-related knowledge. The seminars also provided opportunities for integration of particular experiences within the broader context of the health care organization and the health field. The Association of Field Practice Educators, an organization of social work administrators and field instructors, is represented on all policymaking bodies of the faculty of social work.
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Many of the social work administrators and educational coordinators in the health care settings were active members of the association and participated in developing curriculum policy and program change. Through developing teaching centers, offering practicums to a substantial number of students, and participating in the Association of Field Practice Educators, a productive working relationship developed between social work administrators and educational coordinators and faculty members. These activities provided the foundation for developing a model of collaborative research that emanates from the educational partnership but focuses on practice issues rather than student education.
STEPS IN THE DEVELOPMENT OF A COLLABORATIVE RESEARCH PROJECT Needs Assessment
A survey of the research interests, needs, and capabilities in 10 health settings was conducted over a four-month period. Needs assessment was conducted through individual interviews guided by a standardized questionnaire. Although a few social work departments, particularly those in institutions where a major goal was research, were already involved in research projects, the majority of social work departments interviewed were not conducting any studies. Responses were characterized by marked commonality. All participants readily acknowledged the importance of research and linked this concern with organizational pressures for quality assurance and accountability. However, heavy staff workloads, budget cutbacks, and constant demands to defend social work programs and their effectiveness left the social work administrators feeling overburdened and beleaguered. Although they valued research, they rarely had resources for projects. Most administrators believed there was merit in pooling the respective expertise of the faculty and the setting in identifying a question of mutual interest. These 10 settings made an initial commitment to work together to develop an action plan.
Workshop
A workshop was convened to present the results of the needs assessment. Because all participants experienced conflicting feelings about engaging in research, it was necessary to identify negative as well as positive feelings. Many participants felt that the proposed research constituted another expectation or demand from the faculty. Mistrust regarding the faculty's motivation was evident. Was this interest in practice research a veiled way of changing practicum education and demanding more of field instructors? It was important to clarify the faculty's stance in this regard. A closer integration of practicum, practice theory, and research was recognized as ultimately desirable for social work; however, the objective at this stage was to form a consortium to develop a research project responsive to the practice knowledge needs of the settings. As participants worked together they saw that the faculty did not have a hidden agenda. Repeated discussion and clarification of the issue was helpful in developing trust. It was also important that everyone was able to express concerns directly so these concerns could be addressed. This type of project needs participants and facilitators who will ensure that contentious issues are aired and dealt with. Although communication was important to initiate the collaborative research relationship, the ongoing behavior of the members appeared most critical in facilitating the partnership and allaying mistrust. The positive feelings emanating from a shared belief that empirically derived practice knowledge is necessary and useful to achieve positive practice outcomes propelled people to join a consortium. They realized that objective data could help social work administrators respond to organizational pressures to demonstrate the effectiveness of their services. In university hospitals, research is accorded high status, and through participation in a consortium those social work departments would be serving their organizations' mandate for research. By the end of the workshop, the cohort of representatives from health settings decided that rather than engage in a number of small
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individual projects, it was desirable instead to develop a research consortium in partnership with the social work faculty. Each setting appointed a representative, often the director of social work. The following four working principles emerged: 1. For participating social work departments, research would become an objective supported by senior administration. 2. A common theme would be identified for study that would be important to all settings. 3. The theme should be of interest to both frontline staff and social work administration. 4. The product of the research should be useful in practice. Identification of a Common Theme and Research Topic
Over a four-month period, a consultative process was undertaken within and among organizations to delineate a research topic. The consortium consisted of acute care general hospitals, a pediatric hospital, a health complex serving elderly people, a hospital specializing in chronic care and rehabilitation, and a center specializing in addiction treatment. All participants recognized that the capacity of the consortium to obtain research funding would be strengthened by the number and diversity of settings. In addition, a university–multiorganization research partnership was likely to be accorded higher status in each organization than a single department research initiative. Hence, it was in everyone's interests to find a theme broad enough to encompass the specific practice issues of the various settings. The researchers suggested that data be analyzed separately for each setting to yield information useful to particular organizations and to permit comparisons between them. The representatives from each setting engaged in discussion with their social work staff to elicit their perceptions of important practice questions needing empirically based answers. Early frontline staff involvement was seen as critical for a number of reasons. Their input would help ensure that research questions would lead to increased practice knowledge 226
and effectiveness. It was important to identify and respond to staff concerns that could become barriers to research so that cooperation in the implementation phase would be more likely. Early staff involvement was seen as important to enhancing the chance of appropriate use of the findings. Topics that emerged from the discussions in the 10 health care settings included a methodology to determine the rational allocation of social work resources according to professional knowledge, skill, values, and organizational needs; the development and use of instruments to screen for high social risk; the role of social services in the care of the aged population; social work methods for serving an increasing ethnic population; the development of valid and reliable methods to facilitate productivity; and the development of social work methods to enhance family involvement in the care and management of patients. The following criteria were applied to all the topics in an attempt to develop a priority list: potential for funding, perception of the topic as important by frontline staff, low staff time requirement, ready availability of the data to be collected, and collection of data from staff rather than from patients to simplify ethical review across settings. These criteria were applied to all the topics generated from discussions with more than 100 social workers in the 10 settings. The topic they developed—to develop and test an instrument to screen for high risk that would be capable of identifying the need for family involvement in the effectave and efficient management of patients—was chosen because it met the criteria and represented an issue of sufficiently broad appeal to all members of the consortium. This topic seemed particularly pertinent because an increasing awareness has emerged regarding the role of the family in the medical treatment of illness and disability. Social work traditionally has addressed the psychosocial impact of illness on family stability and the health of family members. Therefore, it is important to identity indicators and predictors for referral of family members for social work services. The researchers decided to develop a screening instrument to facilitate social work services to the
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most needy families. It was expected that such an instrument would assist in the later identification of social work technologies that facilitate quality care for families and would create practice standards of social work for families in health care settings. Preliminary Funding
Any research development activity needs a thorough literature review, instrument development and administration, preliminary data analysis, and the writing of complex funding proposals. These activities require funding. This need must be acknowledged at the outset, and the university should provide start-up funds or research assistance. Fund-raising plans for all participants should allo be developed immediately. Faculty presented a preliminary funding proposal to the university for start-up funds and developed a flow chart of the steps in the research process (Figure 1). The university provided a small research grant. Many consortium members sought funding from their respective institutions. Interhospital rivalry was used productively by the participants to convince their hospital administrators to participate, as was the uniqueness of the large number of participating organizations in partnership with the university. The 10 participating health care settings contributed the requested amount of $500. Literature Review
Suggestions for appropriate literature for review were secured from all staff. The researchera employed a social worker from one of the health care settings to conduct a preliminary analysis of the literature. When funds were secured, a research associate was hired to complete a systematic literature search and review (Bergman, Aggey, Bogo, & Wells, 1990). The literature indicated a lack of previous work in the area and was not specific in defining high-risk indicators for family referral, although there were many reports of the importance of work with families. High-risk screening instruments for general social work referral tend to
identify patients without families as being in special need of social work services. IMPLEMENTATION
Because of the lack of current research and the accepted belief that severity of need or high risk is a judgmental phenomenon and should be defined by the opinion of expert clinicians and theoreticians (Gustafson et al., 1986), the authors tapped the opinions of social work practitioners. The Delphi method was chosen and used in two rounds over a six-month period. The Delphi method is a means of obtaining expert opinion in a systematic manner. Developed in 1984, it is one of a group of methods used in health care and other fields to obtain consensus. The Delphi method is a communication process that facilitates the merging of diverse opinions from a dispersed population into a collective decision. Participants complete a mailed questionnaire. The results are tabulated and reported to the group. These results lead to more specific questions in the second "round," and again results are tabulated and reported. This iterative process continues until sufficient information exchange has been obtained (Delbecq, Van de Ven, & Gustafson, 1975). The advantages of the Delphi method are that each participant can express ideas independently while ultimately providing information generated by an entire group (Fink, Kosecoff, Chassin, & Brook, 1984). The process is relatively easy to understand and implement, and it is flexible in that the number of rounds can be adjusted to meet research needs. lis reliability increases with the size of the group and the number of rounds (Fink et al., 1984; Starkweather, Gelwicks, & Newcorner, 1975). Most commonly, three rounds have proved sufficient to attain stability in the responses; further rounds tended to show little change, and excessive repetition was not acceptable to participants (Linstone & Turoff, 1975; Thomson & Ponder, 1979). Consortium faculty members developed a draft questionnaire. The group reviewed the questionnaire to ensure that questions were clear and could be answered by social workers in their settings. This review served as a pretest.
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Figure 1. Steps in the Development of High-Risk Scale for Social Work Referral of Patients' Families
Literature Analysis Phase 1
Review related instruments
Analyze research and theoretical literature
Expert Input
Instrument Development
Validity Analysis
Reliability
Use modified Delphi to tap expertise of social work practitioners
Compile expert judgments
Assemble pool of 200-300 ► items
Review (by practitioners) to ensure comprehensiveness and content validity
Conceptualize~Review (by dimensions to panel of judges) be measured to establish construct validity Phase 2
Select references to literature
Develop list Review by one ► of indicators--► social work practitioner Revise list
Phase 3
Option 1: Use multiattribute decision analysis to develop and revise instruments Option 2: Test on Perform closed factor cases and item analysis analysis
Revise instrument
Phase 4
t
Field test
Use Cronbach's alpha to compute reliability of factors as well as dimensions conceptualized by researchers
Social workers in each of the social work departments in the health care facilities that formed the consortium completed the questionnaire. The first Delphi round asked them to iden in relation to their service, high-risk situations in which the patient's family should be referred for social work services. They were also asked to identify contraindications for such referrals. This round generated 263 indicators for family referral. These indicators were then grouped into 15 categories. At this stage the goal was to be inclusive, and there was some repetition of items across categories. The second Delphi round asked participants to rate each indicator on a four-point scale, ranging from 1 = not important to 4 = very important. They were also asked to identify the four most important indicators in each category. Space was provided to allow participants to add additional items or make other comments. Consortium members, because they meet frequently, were well connected to the research. The frontfine social workers' interest in the project varied between settings and affected their interest in completing the questionnaires. Connection of staff to the research was established through a representative, usually the social work administrator, in each setting. This person oriented staff to the research and sought their participation in the Delphi rounds. More direct connections between the social workers and the entire consortium would likely have led to a greater sense of involvement. A research day between the two Delphi rounds might have achieved this goal. In most instances representatives obtained a high return rate from the social workers. In some settings internal department difficulties, such as workload assignments, authority issues, and interpersonal conflicts, were displaced onto the research. Social workers who had negative experiences with the faculty as former students or as field instructors also used the research as a target for unresolved feelings of dissatisfaction. It was important for the setting representatives to share these negative reactions from the staff with the consortium. Representatives shared these reactions because consortium members trusted each other to maintain confidentiality
and to support the representative who had been the recipient of criticism about the research. Consortium members also needed to differentiate whether criticisms provided objective and useful feedback about the project or were subjective responses to other issues. There were 196 respondents from the 10 health care facilities. Eighty-two percent had a master of social work degree, 10 percent had a bachelor of social work degree, and 8 percent had social services diplomas or other qualifications. The range of services covered reflected the span of hospital departments. Medicine was the most frequent service reported, followed by psychiatry, geriatrics, rehabilitation and chronic care, and surgery. Surgical areas were frequently carried as a secondary service. More specific services such as intensive care and crisis units, addiction treatment, and acquired immune deficiency syndrome—related care were also identified. Twothirds of the workers reported that more than 75 percent of their assessments included families. There were no major differences across services in indicators of high risk. However, people who worked with children and elderly people identified abuse as an indicator more frequently than those serving the general adult population. After the second Delphi round, the responses were analyzed to identify the items that the respondents rated as indicators of high risk. The consortium members reviewed this list to eliminate duplications. The result was an item pool of 57 listings in 12 categories (Table 1). Thus, the Delphi's first round generated an item pool and the second round provided a rating of the importance of each item as a high-risk indicator for family referral. The results provide a basis for the development of a screening instrument. At this stage a more sophisticated methodology was needed to test and refine the screening instrument. The research consortium developed a major proposal that was submitted to an external funding agency, where it is currently under review. ISSUES IN COLLABORATION
Germain (1984) noted that to achieve effective teamwork, problems related to goals, roles,
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Table 1. Second-Round Delphi Results of the Research Consortium: High-Risk Indicators for Social Work Involvement with Families Indicator
Examples and Comments
Request for social work involvement by patient or family Identification of family problem by patient Problems at initial contact
No apparent organic basis to presenting complaint Presenting symptom related to social stresses, emotional factors, and psychological factors Alcohol abuse or drug use symptoms
Protection concerns
Concern about patient or any family member Physical injury, especially repetitive and unexplained or ambiguously explained injuries Possible neglect, indicated by disheveled, uncared for, or malnourished appearance or lack of visitation by family Possible financial exploitation Sexual abuse or assault Threats to others or self Concerns expressed by patient or family member regarding safety
Basic needs
Employment Finances Home help Help locating, accessing, and using community services Child care Accommodation Transportation Immigration status
Capability of involvement in decision making
Physical or language problems Inability to receive and respond to information in an age-appropriate way Age-inappropriate behavior Confusion in patient
Impact of illness and disability
Illness that affects lifestyle, job, education, activities of daily living, or relationships Catastrophic or life-threatening illness Terminal illness or palliative care Disease that necessitates role changes in family Sudden death of family member Adaptation to chronic illness by patient and family Diagnosis of life-threatening illness (chronic or short-term)
Patient adjustment
Difficulty coping with illness and its diagnosis, prognosis, treatment, or hospitalization Lack of acceptance of limitations and changes resulting from illness Excessive fears, denial, guilt, anxiety, and sadness in patient (continued)
Table 1. Continued Indicator
Examples and Comments
Family characteristics and adjustment
Difficulty managing or coping with patients' behavior Family members' need for help coping with diagnosis, prognosis, treatment, hospitalization, and patient's emotional status or behavior Excessive fear, denial, guilt, anxiety, and sadness in family Need expressed by family for education or guidance regarding coping with member's situation or mental problems Evidence of numerous stress factors, including death, illness, surgery, disability, loss of job, loss of financial resources, relocation issues, and immigration Family avoidance of contact with patient Unplanned or unexpected life transitions, such as crisis occurring at birth, marital or family breakdown, separation of family members
Discharge planning
Need for long-term care or rehabilitation placement Complex, painful, or difficult discharge planning process for patient or family members Need for ongoing support of family on discharge Anticipation of problems on discharge by patient, family, or staff Conflict because of cultural attitudes toward meeting care needs (for example, intergenerational responsibility)
Family caregivers
Issues raised by family in relation to caregiving Evidence that caregiver is struggling or handling patient poorly Inability of family to take on caregiving responsibility (shown by unwillingness, ambivalence, or reluctance) Need by caregiver for guidance, support, and help in decision making Concern about parent's ability to care for child Limited social and family support Suspected alcohol abuse or drug use in caregivers
Family dynamics
Family members fighting, arguing, and disagreeing Family members interfering with planned treatment Patient upset by family behavior Visiting patterns problematic or unusual (for example, family members always or never present) Uncertainty about keeping child Unresolved issues related to reconstituted families
procedures, and organizational issues must be addressed. Goal-related issues needed to be resolved as consortium members struggled to achieve a common purpose. Role-related issues were illustrated by the initial ambivalence of members and when concerns of trust, hidden agendas, and leadership were raised. Procedural issues caused problems when the consortium collected data and at the same time identified whether resistance of some members was related to the task at hand or to preexisting interpersonal issues. The support of the respective organizations in the consortium was seen as a major contributing factor to its establishment and continuation. Both the university and the health care settings identified research activities as an objective. However, actions were needed to demonstrate this commitment. In this instance all the settings provided requested resources such as funding and release time for staff to attend consortium meetings. The involvement of 10 health care settings strengthened the perception that the social work health research consortium was innovative and engaged in a study of significance for social work and health care. The administrations of the settings valued the joint enterprise with the university and in some instances gave it higher status than on-site social work research. During the project's first two years, the majority of the members representing the settings changed employment. The commitment of all settings to the project allowed for continuity, as new representatives were expected to join the consortium and continue the work. Motivation and Trust in the Working Group
Typically, university-based researchers formulate a research topic and use a practice setting to obtain data. As a result consortium members were concerned about the motivation of faculty outreach. Were faculty members operating out of self-interest? Did they have a hidden agenda? Would agency social workers do the work and the faculty take credit? How would agency-based social workers benefit? Would faculty manipulate the decision-making process? These con232
cerns led to challenges about faculty motivation and control. Similarly, faculty had reservations. Would they invest time and energy in developing the project only to find resistance to implementation? Could a group of 12 social workers from a variety of settings and with varying research backgrounds work productively? Would there be equitable involvement in tasks and sharing of credit? These concerns about motivation and self-interest of participants coupled with the problem of changing agency representation could have been major barriers to progress. Consortium members were skilled in collaborative practice; it was part of their function as social workers in health care (Germain, 1984). Typically they used confrontation—that is, open discussion of concerns and differing opinions, analysis of causes, and problem solving—rather than other styles of conflict management such as avoidance or forcing a solution through exertion of power (Rubin & Beckford, 1972). Thus, problems were reframed as opportunities for consolidating the working alliance among consortium members. Leadership Roles
Initially the faculty provided leadership, but increasingly the agency members assumed greater responsibility by supporting each other, ensuring absent members were updated, and working together in subgroups. The start-up funds facilitated an initial literature review. As work progressed, the tasks became clearer and commitment strengthened. Members developed the enthusiasm to convince the senior executives in their organizations of the importance of the project, to enlist their support, and to raise funds from hospital administration. The social work directors' skill in influencing their administration and the faculty members' expertise in writing funding proposals were pooled to produce a brief proposal to secure funds from the health care settings. Agency members supported each other in developing strategies and tactics to gain the commitment of their social work staff and to engage them in data collection via the Delphi method. Success in fund-raising and in obtaining thoughtful staff responses to the
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Delphi heightened the sense of purpose and confidence. In the early phases representatives from the settings changed frequently. New consortium members had to be educated about the project and brought into the group. As each new member joined, their questions about the project stimulated the ongoing group to clarify the work and attend to issues that had been overlooked. This process strengthened the work, as it resulted in frequent review and created group cohesiveness. Data analysis brought a new phase to the process. The faculty analyzed the results of the first Delphi round. After the second round, the faculty demonstrated the tasks involved, the members formed subgroups to work on different sections, and the subgroups brought their results back to the whole group for consensus decisions. Thus, the consortium was involved in the conceptualization of the project and many handson activities such as writing the proposal, evaluating the questionnaire, and defining behavioral indicators in the draft screening instrument. The consortium members worked on these tasks in small and large groups, pooling and sharing expertise. The success of the collaboration appeared to rest on certain characteristics of individual members that resulted in a productive, task-oriented team. Social workers tend to value and be skilled at behaviors that encourage cooperation, positive feedback, development of trust, respect for individual contributions, active problem solving, and direct and open communication. Members risked raising contentious issues regarding power, status, ownership, and hidden motivations. Members remained committed to the task and followed up on assignments. As a result of the success of the collaboration the consortium members decided to apply for a major research grant. This decision demanded a renewed commitment. A junior faculty member was recruited initially to write a literature review and then as a full member of the group to play a primary role in gathering the material required for the proposal. Again the faculty members provided leadership and resources in the
form of staff experienced in research and access to consultation from a range of experts. The consortium opened its membership to include as coinvestigators two academicians, one from social work and the other with a social work background but from the faculty of medicine. Both of these investigators had specialized skills in the research method that had been chosen for the next phase of the research. Again, issues of prestige and control resurfaced. Animosity and resistance were expressed and resolved through a process of reclarification of purpose and role. CONCLUSION
In contrast to research based on outside consultation, the social work health research consortium used a collaborative model that involved all participants in collegial activity. The institutional relationships and accompanying university appointments provided a structural link that was used to involve the social work departments at the initial stage. Because all contributors were seen as equally necessary for the project to be successful, an atmosphere of respect developed in which participants interacted as tolleagues. Group decision making was done by consensus, with influence connected to expertise rather than to a specific role. The outcome of this consortium thus far is the development of conceptualizations of risk factors for social work involvement with families in health settings. The consortium also highlighted the visibility of social work expertise with such families. Research participants gained increased knowledge of research methodology and grantsmanship, and the credibility of social work research in the health care settings was enhanced. Societal pressures for accountability and efficiency support systematic studies, as illustrated by an openness to research on the part of both the institutions and their staffs in this study. In this era of changing demographics, rising health care costs, and shrinking resources, all health care professionals are challenged to find the most effective methods of promoting health and minimizing the negative effects of illness.
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Research activities can help address these concerns and determine effective social work practice interventions. Collaboration between social workers in university and health care settings can provide a fruitful means to advance the empirical base for practice. About the Authors
Marion Bogo, Adv. Dip. SW, is Social Work Practice Professor and Field Practicum Director, Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, Ontario, Canada M5S 1A1. Lilian Wells, Adv. Dip. SW, is Professor and Associate Dean, Faculty of Social Work, University of Toronto. Sharon Abbey, MSW, is Senior Social Worker, Sunnybrook Health Science Centre, Toronto. Ann Bergman, PhD, is Social Work Practice Professor, Faculty of Social Work, University of Toronto. Verna Chandler, MSW, is Director, Social Work Department, Mount. Sinai Hospital, Toronto. Leota Embleton, MSW, was Director, Social Work Department, Queen Elizabeth Hospital, Toronto. Samira Guirgis, MSW, was Senior Social Worker, Addiction Research Foundation, Toronto. Anne Huot, MSW, was Senior Social Worker, Mississauga General Hospital, Mississauga, Ontario. Ted McNeill, MSW, is Director, Social Work Department, Hospital for Sick Children, Toronto. Linda Prentice, MSW, is Senior Social Worker, St. Michael's Hospital, Toronto. Dan Stapleton, MSW, was Director, Social Work Department, Toronto East General Hospital, Toronto. Lorie Shekter-Wolfson, MSW, is Director, Social Work Department, The Toronto Hospital, Toronto. Sorele Urman, MSW, is Director of Central Intake, Baycrest Centre for Geriatric Care, North York, Ontario. References
Baker, C. M. (1981). Moving toward interdependence: Strategies for collaboration. Nurse Educator, 6, 27-31. Bergman, A., Abbey, S., Bogo, M., & Wells, L. (1990). High-risk indicators for family involvement 234
in social work: A review of the literature. Unpublished manuscript, University of Toronto, Faculty of Social Work. Caroff, P., & Mailick, M. D. (1985). Health concentrations in schools of social work: The state of the art. Health and Social Work, 10, 5-14. Delbecq, A. L., Van de Ven, A., & Gustafson, D. H. (1975). Group techniques for program planning. Glenview, IL: Scott, Foresman. Engstram, J. L. (1984). University, agency, and collaborative models for nursing research: An overview. Journal of Nursing Scholarship, 14(3), 76-80. Fink, A., Kosecoff, J., Chassin, M., & Brook, R. H. (1984). Consensus methods: Characteristics and guidelines for use. American Journal of Public Health, 74, 979-983. Germain, C. B. (1984). Social work practice in health care: An ecological perspective. NewYork: Free Press. Gustafson, D. H., Fryback, D. G., Rose, J. H., Yick, V., Prokop, C. T., Detmer, D. E., & Moore, J. (1986). A decision-theoretic methodology for severity index development. Medical Decision Making, 8, 27-35. Haunch, A. S., Chance, H. C., &Atwood, J. (1981). Research in practice: A process of collaboration and negotiation. Journal of Nursing Administration, 11, 33-38. Irvine, A. A., Phillips, E. K, Fisher, M., & Cloonan, P. (1989). Out of the ivory tower: The value of collaborative research. Home Health Care Services Quarterly, 10, 117-130. Linstone, H. A., & Turoff, M. (1975). The Delphi method: Techniques and applications. Reading, MA: Addison-Wesley. Marshack, E., Davidson, K., & Mizrahi, J. (1988). Preparation of social workers for a changing health care environment. Health and Social Work, 13, 226-233. Musci, E. (1987). Collaboration: The key to research feasibility. Oncology Nurse Forum, 14, 84-85. Reinherz, H., Grob, M. C., & Berkman, B. (1983). Health agencies and a school of social work: Practice and research in partnership. Health and Social Work, 8, 40-47. Rubin, I. M., & Beckford, R. (1972). Factors influencing the effectiveness of health teams. Milbank Memorial Fund Quarterly, 50, 317-335.
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Starkweather, D. B., Gelwicks, L., & Newcomer, R. (1975). Delphi forecasting of health care organization. Inquiry, 12, 251-262. Thomson, W. A., & Ponder, L. D. (1979). Use of Delphi methodology to generate a survey instrument to identify priorities for state allied
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health associations. Journal of Allied Health and Behavioral Sciences, 2, 383-399. Young, C. L. (1986). Social work roles in collaborative research. Social Work in Health Care, 11, 71-81. Accepted July 30, 1991
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